MEDICARE: MS. KRISTIN NICOLE WILSON NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	CNP-02899	NM
2	363L00000X	Nurse Practitioner	202000961NP-PP	OR

General Provider Information

NPI Number	:	1851747596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTIN NICOLE WILSON NP-C

Provider Business Mailing Address
First Line	:	2011 4TH ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2511
Country	:	US
Telephone Number	:	541-963-4139
Fax Number	:	541-429-6612

Provider Business Practice Location Address
First Line	:	2011 4TH ST
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-2511
Country	:	US
Telephone Number	:	541-963-4139
Fax Number	:	541-429-6612

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2016
Last Update Date	:	04/28/2020

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